Patient Safety - Medical Examiners
As a result of several high-profile public inquiries, acute trusts in England were asked to start setting up medical examiner offices through 2019/20, initially to provide an independent review of non-coronial deaths that occur in their own organisation. A new statutory Medical Examiner System has now been introduced across England and Wales to provide independent scrutiny of deaths, and to give bereaved people a voice.
From 09 September 2024 all deaths in any health setting that are not investigated by a coroner will be reviewed by NHS Medical Examiners. There will be a new medical certificate of cause of death (MCCD) and medical practitioners will be able to complete an MCCD if they attended the deceased in their lifetime.
The aim of the Medical Examiner Service is to:
- Provide bereaved people with an opportunity to give feedback about the care their loved one received, ask questions and raise concerns.
- Enhance safeguards for the public and healthcare providers through improved and consistent review of non-coronial deaths.
- Improve the quality and accuracy of medical certificates of cause of death and ensure that coronial referrals are appropriate and accurate.
- Support local learning and improvement by identifying matters for clinical governance and related processes.
- Align with initiatives such as Learning from Deaths.
The role of the Medical Examiner (ME) is to review non-coronial deaths in order to:
- Agree the proposed cause of death with the attending doctor and ensure the accuracy of the medical certificate of cause of death (MCCD).
- Discuss the cause of death with bereaved people or informant in lay terms and establish if they have feedback they would like to give about the care, that could have impacted or led to the death. These conversations can be allocated to the Medical Examiner Officer (MEO) at the Lead ME's discretion.
- Be a medical advice source to the local HM Coroner.
- Highlight a selection of cases where concern has been raised by either family, healthcare staff or the ME, for further review under local mortality arrangements and other clinical governance procedures.
